Provider Demographics
NPI:1740380963
Name:GREAT PLAINS DERMATOLOGY, P.A.
Entity Type:Organization
Organization Name:GREAT PLAINS DERMATOLOGY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:TILLMAN
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:785-625-7546
Mailing Address - Street 1:2708 STERNBERG DR
Mailing Address - Street 2:
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601
Mailing Address - Country:US
Mailing Address - Phone:785-625-7546
Mailing Address - Fax:785-625-7598
Practice Address - Street 1:2708 STERNBERG DR
Practice Address - Street 2:
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-1922
Practice Address - Country:US
Practice Address - Phone:785-625-7546
Practice Address - Fax:785-625-7598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0523958207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS016813Medicare ID - Type Unspecified
KSE97022Medicare UPIN